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Subscribe to RSSFormer Medicaid and Medicare director Donald Berwick says few states were likely to reject the Medicaid funds despite the court's decision.
Updated at 7:04 p.m. ET: Now that the Supreme Court has upheld President Barack Obama's health care initiative, will Congress have to rewrite it from scratch?
It's not a paradoxical question. The court signed off on nearly all of the Patient Protection and Affordable Care Act, but it struck down one provision, and in doing so — whether it knew it or not — it may have put the poorest Americans at the greatest risk of being left without any health insurance.
Chief Justice John Roberts said as part of the 5-4 decision that states can't be penalized for refusing to join the law's expansion of Medicaid eligibility. Health law experts said that had the practical effect of flipping an all but mandatory program into one a state can choose not to join.
Here's the problem: The ACA creates state health insurance "exchanges," providing tax credits to eligible residents to buy affordable, state-certified health insurance. But the poorest Americans aren't in that eligible pool, because the law assumes they'll be covered by the expansion of Medicaid, which is no longer a given.
In states that reject the expansion, poor residents could be left without either form of coverage — as many as 15 million if all 50 states opt out, a circumstance that former Medicaid director Donald Berwick said was highly unlikely.
The White House didn't address the issue in a long Q&A it issued on the court's decision. The statement touted every provision of the act but one: Medicaid expansion.
Medicaid currently covers only some low-income people, primarily parents with children, pregnant women, people with severe disabilities and senior citizens. Adults without disabilities or children, in other words, aren't generally covered. That's the group the Medicaid expansion was supposed to help the most.
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If their states opt out, young working adults below the poverty line could be in a Catch-22, because "they may not get Medicaid, and they may not be eligible to purchase insurance through the exchange," said Christina S. Ho of the Rutgers University School of Law, who was a member of President Bill Clinton's Domestic Policy Council.
It works this way:
The insurance tax credits are targeted at people with incomes between 100 percent and 400 percent of the poverty line as determined by the U.S. Census Bureau. Congress sought to compel the states to cover everyone under the line through Medicaid.
The federal government promised to fully cover all expenses for the expanded coverage before eventually pulling back to cover 90 percent after a few years. The states would have to pick up the extra 10 percent eventually.
States aren't required to take part, but if they don't, the law as enacted would have turned off the flow of all Medicaid funding from Washington.
That enforcement mechanism is what the court invalidated Thursday, meaning there's no penalty for a state that says, "Thanks, but no thanks."
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Because states haven't had time to consider yet whether they will opt in or out. it's difficult to say how many people could be affected.
But about half of the nearly 50 million uninsured Americans have incomes below the new eligibility thresholds, according to the latest report, in October, from the Kaiser Commission on Medicaid and the Uninsured. And about 6 in 10 of them are adults without dependent children — the primary beneficiaries of the program's expansion.
If you do the math, roughly 15 million Americans could be in the newly created gray area. In 2010, when the act was passed, the Commonwealth Fund, an independent health care policy foundation, similarly calculated that the Medicaid expansion would benefit 12 million of the 15 million uninsured Americans under the poverty line.
Donald Berwick, former head of the Centers for Medicare and Medicaid Services, which administers the two programs, said few states were likely to take that risk.
"Those people are still living in your state, They're still poor. They're going to come to your emergency room. They're going to be operated on, and they're going to have diseases that get worse, and you're going to have to pay for that. That will come from the state — free care pools and charity in the state," Berwick said in an interview on MSNBC-TV.
"I think what's going to happen is the states are going to be under pressure from providers of care who say: 'Why are you leaving this money on the table? Let's join in with the federal dollars.'"
But Judy Solomon, vice president for health policy at the nonpartisan Center on Budget and Policy Priorities, agreed with Ho that the decision means low-income adults could lose the promise of Medicaid coverage "even while people with somewhat higher incomes will be eligible for premium tax credits."
Writing on the center's policy blog, Solomon said: "The poorest adults — primarily parents and other adults working for low wages — will be left out in the cold."
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It's the "have's and have-not's". I have so I don't care what anyone does
So now we know that Obamacare was really shutdown for the voters he counts on.
The reality is this, insurance costs will go up and up and up and the government will force you to pay more and more and more.
1) the insurance companies will be forced to cover people no matter what. this will cost them millions who do you think is going to foot this bill...THEM nope... the government hell no. Yep we will all have to pay for this.
I wanted to get my wife on the insurance through the company I work for. The cost to do this with NO existing or past serious health issues was $1990.00 a month. I get paid on the first and 15th and I bring home 1700 a pay day. What this law does is force me to either pay this OR give the GOVERNMENT 5K a year.
Do you think I will qualify for assistance???????
The government does NOT CARE ABOUT YOUR HEALTH. This is just a way to make more TAX money.
At the current rate of insurance costs it would cost me 23000 a year to cover my wife. It will be MUCH cheaper to just pay the tax............
the government KNOWS this will be the case for most middle class people without children.We are in our 50's and do not have children.
IT'S A REVENUE STREAM AND NOTHING MORE...... THE MIDDLE CLASS PAY AND THE RICH GET A TAX BREAK....
The insurance Companies do not care about your health...all they care about is their 20%profit margin they are after all a business and like all others they must make a profit to stay viable.
There is no good solution to the health care problem other than FAIR TAXATION AND THE MONEY COLLECTED ACTUALLY GOING ONLY TO PAY THE MEDICAL COSTS.
But we all know that the government can not do that... look at the GAS TAX. This money is supposed to go for infrastructure maintenance. It is instead used for what ever congress wants to use it for. It all ends up being put in the general use funds by vote.
OBAMA and the rest of the government think we are all fools.......
THE ONLY WAY TO PROVE THEM WRONG IS TO VOTE THEM ALL OUT....CLEAN SLATE 2012 After all we can get rid of them all again in 4 years untill we find a group that is actually intrested in making this country great again.
Stalkit, since you're so sure that health costs will go up under the ACT could you tell me what the stock market is going to do tomorrow? You must have some incredibly perceptive skills, pal.
Stalkit, since you're so sure that health costs will go up under the ACT could you tell me what the stock market is going to do tomorrow? You must have some incredibly perceptive skills, pal.
No, you're wrong. The insurance companies are the ones who did not care about your health.
Yes, you will get subsidies so that both you and your wife will be able to afford insurance.
Are you suggesting that premiums haven't been going up or that deductibles haven't been increasing?
It's because of this law that insurance companies now have to give back to their consumers. 80% of the premiums must now be used to care for their customers. This law is now the reason that wellness checkups are free. They come out of the insurance company's pockets rather then the money going into the CEO's pockets as bonuses.
So how do you figure that the govt. is the one who doesn't care about you?
For those who claim they are unable to afford insurance, how can you afford to be without it? Who pays your huge medical bills? I already know the answer to that, but just want to hear someone admitting they use the ER and the people with insurance and the counties pick up the tab for their care now.
What the author of this article conveniently fails to address is the question of why would States opt out of the ACT Medical reimbursement plan? Unless they're being governed by ideologically right wing politicians there are few reasons that any State would do so. Why is that so hard to understand?
If you thought obamacare was for the poorest of the poor you are dunb and dumber. People just get stupid and more stupid. If you cannot afford medical insurance now you will not be able to afford after this scam either.
jerry, such a well-reasoned and totally uniformed comment. Congratulations.
Now it is time to reach out and include Health Care for those in Poverty who are not covered by any Health Care.
This is America, we must take care of our own.
Actually, no.
We just impose a penalty or tax, or whatever on those in poverty for lacking health insurance.
Thank you, Obama!!
This law does reach out to the impoverished. Medicaid is being expanded. We're finally moving in the right direction and caring for our own!
Thanks Penelope2, I am happy to know that we are moving in the right direction.
This is America, it is time to move the middle class into the upper class, the working class into the middle class and eradicate poverty in the United States of America.
Free market to me is where every one is able to play on a level field.
Health Care for all, rich, upper class, middle class and working class alike. even those who are below working class, they are people also.
Jack
It's pretty simple first grade math.
If the insurance companies suddenly have millions or billions more going out on coverage, they have to re coop this somewhere.
They can't eat it, and the government will not help them , they are after all a business not a government entity.
So who does this leave to foot the bill. The MIDDLE CLASS!!!!!!
We need to get the governments attention, vote them ALL out.. demo. rep. lib. ALL of them... This is the only way to get this machine running properly. If the next set is not functional then clean em out again in 4 years.
stalkits.. how many people do you think are sick and use their healthcare? Of all the people I've known only a few have been sick. If everyone, (the majority healthy) and the rest all pay into the system yes the insurance companies can afford it. My god the insurance companies fooled you into thinking they pay out all of their money on claims when in fact they are making quite a fortune off of us suckers.
stalkit, don't buy into the fear-mongering going on at Fox and the insurance companies. There is absolutely no evidence that rates will go up unless you read the garbage being put out by the Heritage Foundation or some other right wing think tank.
And btw, the insurance companies are doing just fine from a profitability standpoint If they can spend 30-40 cents on every dollar of premium revenue on exhorbitant salaries and outrageous marketing expenditures I'm sure they can find a few pennies someplace to shoulder whatever financial burden the ACT places on them if that were ever come to pass. No tears for them, ok?
Here's a crazy idea -
What if the Dems and the Reps just decide to shrug it off, except the inevitable, decide that they all want to help poor children and poor pregnant women and old folks get health care ....
And then come together and try to make this work for everybody!!!!!
You're right. It's a crazy idea.
More likely the senate & the presidency go republican and the whole mess gets repealed.
In your wild and crazy dreams. Americans aren't all a bunch of fox loving, tea bagging idiots. Some of us are able to read and draw our own conclusions vs. hanging on every fox noise word and adoring the Koch crooks.
Anyone who thinks the Republicans cares about the working poor & the poor. Are only fooling themselves. Whether we live or died. Makes no different to them. They think of us as a burden on society. I read it so many times, I truly believe that.
When are they going to start working on the ECONOMY and JOBS?????
>Solomon said: "The poorest adults — primarily parents and other adults working for low wages — will be left out in the cold."<
And they'll have to pay a tax penalty courtesy of obamacare.
Talk about rubbing salt in the wound.
I wouldn't hold my breath for congress to fix that one either. They'll offer to repeal obamacare instead, which for those poor souls would be an improvement.
This is worse than total obamacare repeal.
Before posting again, please read through the Affordable Healthcare Act. You're spewing fox lies and showing us how ill-informed you are about this whole conversation.
I'm curious Penelope, have you read it? It seems to have an awful lot of sh!te in it that doesn't pertain to healthcare.........primarily, the 3.8%tax on all real estate sold starting 2014.I wonder what my house has to do with my insurance.........
I faxed a sleep study test to the VA 2 weeks ago and still havent got my apointment. Dont get me wrong the VA will come through but it takes a little longer to get an appoint and then you have to wait forever. Also they had to substitute some of my medications. Government run health care is a little different than reg hospitals. If you have to have a lung function test and a 6 min walk done it is done by 2 differnt departments.
A Government Ran Program, the Epitome of Efficiency, You Vets may end up the Lucky Ones, I don't think they can Hose Your system up any worse. Good Luck with That.
I think the goal is to turn all of american medicine into one big VA medical clinic.
And I think with what happened today we are on track to achieve that goal.
If you're a vet, you're used to it. No difference. I think it will be a shock for the rest of us.
That's a fallacy and again, you're spewing lies.
Tricare has excellent coverage and it's dirt cheap compared to regular insurance. Some of the best medical care you can get are from the VA hospitals.
Didn't you serve our country and already know that?
Folks, Grab Your Wallet and Kiss it's Contents Good Bye, Then go in a room with a Mirror and Take a Look at the DumbA$$ who's going to pay for all this Crap. Mr. B.O doesn't give a Damn about who or how he has impacted the Health Care System as we knew it, Mr. B.O. gets Free Insurance for Life. I hope He soon suffers the same affliction as his Comrade in Arms, Hugo Chavez. There is a reason for Checks and Balances, when One Party controls both houses of Congress, Expect some Sex and You might not like it. How's that Hope and Change working out for You?
snooze
sly like a fox. news? dumbed down.
All but 1 state applied for the government funds to set up the programs already so I wouldnt worry about it.
Are you kidding? 26 states filed the suit saying they couldn't afford it. That's what the case was about.
Are you sure the drugs the government is providing you for free aren't LSD or mescaline.
demoblat: NO! 26 republican-led states said they thought the law was unconstitutional. It's nothing about affordability and if you had half of a brain you'd know that.
I love this decision and i'm not for Omabycare! This is going to cause tormoil between the States and Federal Governments! I'm beginning to think Roberts is a genius! In a few years we will have to decide on who we want to control out healthcare,local or federal governments! I bet we chose local.This Obomynation of a tax increase is bad for everyone.Those of oyu wanting to tax the top 1% got it right in the shorts from the number one back shooter(except for Barnie, Frank my in my butt) in the world.Thought Obamy was going to make all those big corps pay your way and you would get off free! I'm laughing at you right now! Vote for him again,maybe,next time he will tax your fone!MORE TAXES,Vote for Obamy-2012!!!
WORLDS' LARGEST TAX EVER!!!! You voted for him,no me! Vote for him again and see what is next!
Vote for your country in 2012...Vote for a change!
Explain how taxes will be going up. Come on. Let's hear it. You must've heard that word in the Supreme Court decision and I want your version of exactly what we will be taxed on.
(Pulls up chair, pops some popcorn, and gets ready for a really good story.)
Yet another completely off-the-wall brain fart from a right winger. If you keep drinking the fear-mongering Kool Aid being vomited by Fox News and the rest of the conservative spin machine you might want to live in your bomb shelter for a while to get your senses back on track. SHEESH!
No, shame on you. Your information is incorrect and you have no idea what you're spewing.
Why do you not want everyone to get a free wellness check, courtesy of the rich, fatcat insurance companies?
Why would you not want children under 26 on their parent's family insurance? Should something happen to them and they aren't insured, the counties foot the bill. Those are tax dollars, too.
Why would you not want someone with a pre-existing condition be able to buy insurance, pay a premium, pay a deductible and copay?
Why would you want to continue seeing the spiraling costs of premiums continue?
I could go on, but you get the picture. Do you even know what is in this law?
The Poor will take it in the shorts again/still, go going Obama
You heard this on fox noise and please explain exactly how or do you just blindly follow?
Medicaid will be expanding and the poor will have more access to healthcare then they do right now.
I really don't understand party line rhetoric. Please tell me who is really benefiting from this? Illinois has a democratic governor, and the state just slashed the medicaid to all low income adults. So to say the poor is always taken care of isn't true. What does this do for all the uninsured working Americans that are hanging on by the skin of their teeth in this economy and now they have to afford paying for insurance. And I can almost guarantee you that it will be a policy with a high deductible, meaning they will still be unable to afford going to the doctor. So when they do end up at the doctor they will be really sick costing the insurance company a lot of money and not doing anything for the cost of health care overall. It seems like we just lost more of our freedom today and nobody, except maybe insurance and drug companies, gained anything.
Jack I do not watch FOX nor do I listen to the GOP rhetoric.
It's pretty simple economics. If the product you produce costs this many dollars to supply you MUST charge more than that to stay in business.
when you suddenly have production cost overages you have to adjust the selling price to stay viable.
If your gross is 25b and your expenses are 18 to 19b then your doing well. Let the expenses suddenly grow to 23 or higher and your now in risk of failure. You as a business have to weigh these risks and change rates as needed... LOOKING FORWARD... This is how rates are set afterall.
Not to worry about tax increases, Obama will be seeking a huge raise in the debt ceiling so he can borrow the money from China to pay for this.
Its your children and grand children and their children who are going to get screwed.
In California, we have a state law called 215, which is known as medical marijuana. Will those who smoke marijuana be "taxed" more in terms of their premiums? if there is no way an insurance company can reject a person for pre-existing conditions, then potheads must buy insurance. But wait, if federal madate trumps state laws, then marijuana is not recognized as legal. so will the potheadas be screwed after all? I hope so. Forcing potheads to drug test is cool to me.
Do you remember when Pelosi said we have to pass this so we figure out what is in it? It's been 2 years and they haven't figured it out yet. This will go down in history for being as bad for America as the Civil War was. What a disgrace our president is.
No, YOU haven't figured it out. Pelosi was making a joke, but the rightwing nut jobs have no sense of humor and have repeated her comment time and time again.
So when the welfare recipients get their check on the 1st the Healthcare TAX will be taken out. Can't wait.
The judge knew exactly what he was doing and the TAX will be enforced on everyone.
and you don't know what you are talking about.
On everyone but the rich. Tax cuts for the rich, freeloaders get more freebies, and the middle class is decimated yet again. Obama's war on the middle continues unabated.